Amlodipine Overdose in a Transgender Woman: A Case Study.

Calcium channel blockers are a major cause of cardiovascular toxicity. The clinical spectrum of these patients is very variable and there is no consensus on the dose required for toxicity. We present a case of a 43-year-old transgender woman who presented with hypotension and tachycardia owing to drug overdose that was later confirmed to be amlodipine. Given the catastrophic cascade of events involved with such toxicities, it is important to highlight amlodipine as one of the causes of drug overdose that can be overlooked.

Dieulafoy's Lesion of the Duodenum: A Rare and Fatal Cause of Gastrointestinal Bleed.

Dieulafoy's lesion (DL) is an unusual cause of recurrent gastrointestinal bleeding that can be fatal. It can occur in various parts of the gastrointestinal (GI) tract, most commonly located in the stomach, especially at the level of lesser curvature; however, it can occur in other parts, including the colon, esophagus, and duodenum. A duodenal Dieulafoy lesion is characterized by the presence of a larger-caliber artery that protrudes through the GI mucosa and can lead to massive hemorrhage. The exact cause of DL is yet to be determined. Clinical presentation includes painless upper GI bleeding, including melena, hematochezia, and hematemesis, or rarely iron deficiency anemia (IDA); however, most of the patients are asymptomatic. Some patients also have non-gastrointestinal comorbidities such as hypertension, diabetes, and chronic kidney disease (CKD). The diagnosis is established by esophagogastroduodenoscopy (EGD), which includes the presence of micro pulsatile streaming from a mucosal defect, the appearance of a fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect, and the visualization of a protruding vessel with or without bleeding. Initial EGD can be non-diagnostic due to the relatively small size of the lesion. Other diagnostic modalities include endoscopic ultrasound and mesenteric angiography. The treatment of duodenal DL includes thermal electrocoagulation, local epinephrine injection, sclerotherapy, banding, and hemoclipping. We present here a case of a 71-year-old female who had a history of severe IDA requiring multiple blood transfusions and intravenous iron in the past and was found to have duodenal DL.

A Rare Case of Kikuchi-Fujimoto Disease.

Kikuchi-Fujimoto disease (KFD) is an autoimmune condition that is more common in females and occurs in the third decade of life. The condition is usually benign and self-resolving and is characterized by fever, cervical lymphadenopathy, night sweats, myalgia, and rashes. The disease can be misdiagnosed as reactive follicular hyperplasia, tuberculous lymphadenitis, systemic lupus erythematosus, and malignant lymphoma. The diagnosis of KFD involves the excision of the affected lymph node. Although there is no specific treatment for the disease, usually symptomatic and supportive measures are effective; however, steroids and immunosuppressive therapies are considered in more severe cases. The disease lasts for around one to four months. The neurological complications include cerebellar ataxia, meningoencephalitis, and aseptic meningitis. Here, we describe the case of a 36-year-old male who presented with complaints of fever, malaise chills, anorexia, and fatigue associated with a tender right axillary lymph node. The patient underwent a biopsy which confirmed KFD and responded well to supportive therapy.

Stauffer Syndrome as the Initial Presentation of Advanced Metastatic Prostate Cancer.

Stauffer's syndrome is a paraneoplastic syndrome that has historically been associated with renal cell carcinoma. It is defined by the anicteric elevation of liver enzymes in the absence of liver metastasis, and the reversibility of clinical and biochemical changes upon treatment of the primary pathology. Here, we discuss the rare presentation of Stauffer's syndrome in a patient with advanced metastatic prostate cancer. A 72-year-old male presented with generalized weakness, dizziness, weight loss, and icterus who was incidentally found to have a prostatic enlargement on physical examination. The laboratory investigations and radiographic imaging confirmed the diagnosis of metastatic prostatic cancer without any evidence of mechanical biliary obstruction as confirmed by biopsy and imaging. The cancer had metastasized to pelvic sidewalls, pelvic bones, ribs, urinary bladder, and local lymph nodes. Our case signifies that a high index of suspicion for underlying cancer should be maintained in patients presenting with cholestatic liver dysfunction, with or without jaundice, especially in the absence of a recognizable mechanical etiology of cholestasis.

Postinfluenza Cardiac Tamponade: A Review of Published Case Reports.

Increased vaccination rates and better understanding of influenza virus infection and clinical presentation have improved the disease's overall prognosis. However, influenza can cause life-threatening complications such as cardiac tamponade, which has only been documented in case reports. We searched PubMed/Medline and SCOPUS and EMBASE through December 2021 and identified 25 case reports on echocardiographically confirmed cardiac tamponade in our review of influenza-associated cardiac tamponade. Demographics, clinical presentation, investigations, management, and outcomes were analyzed using descriptive statistics. Among 25 cases reports [19 adults (47.6 ±15.12) and 6 pediatric (10.1 ± 4.5)], 15 (60%) were females and 10 (40%) were male patients. From flu infection to the occurrence of cardiac tamponade, the average duration was 7±8.5 days. Fever (64%), weakness (40%), dyspnea (24%), cough (32%), and chest pain (32%) were the most prevalent symptoms. Hypertension, diabetes, and renal failure were most commonly encountered comorbidities. Sinus tachycardia (11 cases, 44%) and ST-segment elevation (7 cases, 28%) were the most common ECG findings. Fourteen cases (56%) reported complications, the most common being hypotension (24%), cardiac arrest (16%), and acute kidney injury (8%). Mechanical circulatory/respiratory support was required for 14 cases (56%), the most common being intubation (9 cases, 64%). Outcomes included recovery in 88% and death in 3 cases. With improving vaccination rates, pericardial tamponade remains an infrequently encountered complication following influenza virus infection. The complicated cases appear within the first week of diagnosis, of which nearly half suffer from concurrent complications including cardiac arrest or acute kidney injury. Majority of patients recovered with timely diagnoses and therapeutic interventions.

Association between right ventricular dysfunction and in-hospital mortality in surges of SARS-CoV-2 infection attributed to the Alpha, Delta, and Omicron variants.

Background: Right ventricular (RV) dysfunction in acute COVID-19 was reported to be associated with poor prognosis. We studied the association between parameters of RV dysfunction and in-hospital mortality during the surges caused by different SARS-CoV-2 variants. Methods: In a retrospective single-center study, we enrolled 648 consecutive patients hospitalized with COVID-19 [66 (10 %) hospitalized during the alpha variant surge, 433 (67 %) during the delta variant surge, and 149 (23 %), during the omicron variant surge]. Patients were reported from a hospital with an underreported population of mostly African American and Hispanic patients. Patients were followed for a median of 11 days during which in-hospital death occurred in 155 (24 %) patients [Alpha wave: 25 (38 %), Delta Wave: 112 (26 %), Omicron wave: 18 (12 %), p < 0.001]. Results: RV dysfunction occurred in 210 patients (alpha: 32 %, 26 %, delta: 29 %, and omicron: 49 %, p < 0.001) and was associated with higher mortality across waves, however, independently predicted in-hospital mortality in the Alpha (HR = 5.1, 95 % CI: 2.06-12.5) and Delta surges (HR = 1.6, 95 % CI: 1.11-2.44), but not in the Omicron surge. When only patients with RV dysfunction were compared, the mortality risk was found to decrease significantly from the Alpha (HR = 13.6, 95 % CI: 3.31-56.3) to the delta (HR = 1.93, 95 % CI: 1.25-2.96) and to the Omicron waves (HR = 11, 95 % CI: 0.6-20.8). Conclusions: RV dysfunction continues to occur in all strains of the SARS-CoV-2 virus, however, the mortality risk decreased from wave to wave likely due to evolution of better therapeutics, increase rate of vaccination, or viral mutations resulting in decrease virulence.Registration number of clinical studies: BronxCare Hospital center institutional review board under the number 05 13 21 04.

A Rare Case of Reverse Takotsubo Cardiomyopathy in a 28-Year-Old Female in Peripartum Period.

Reverse Takotsubo cardiomyopathy is a rare variant of Takotsubo cardiomyopathy in which ballooning occurs at the base of the heart rather than the apex, which is hyperkinetic. Takotsubo cardiomyopathy is usually considered in postmenopausal women, but a growing number of cases of the reverse variant are emerging in peripartum women. We present a case of peripartum reverse Takotsubo cardiomyopathy in a 23-year-old G1P0 female at 38 weeks gestation, induced by preeclampsia with severe features. An echocardiogram performed in the immediate post-cesarean period demonstrated a severely reduced ejection fraction of 25%, which was improved to 43% over the next 48 hours with diuresis. Therefore, it is imperative to differentiate Takotsubo cardiomyopathy occurring in the peripartum period from peripartum cardiomyopathy, which has a similar clinical presentation, to diagnose this condition and improve patient outcomes.

Hashimoto's Thyroiditis Encephalopathy Induced by COVID-19 Infection.

Various factors can lead to thyroiditis, including any acute inflammatory process, especially viral illness. While coronavirus disease 2019 (COVID-19) has been linked to disorders of various systems, there is a lack of literature showing an association of coronavirus with the cause of Hashimoto's thyroiditis. Several possible mechanisms for this outcome have been proposed; chief among them is molecular mimicry. Here, we are reporting a case of Hashimoto's thyroiditis incited by COVID-19 in a 34-year-old obese female who presented with anxiety, behavioral changes, and repeated head movements. The patient had an elevated thyroid stimulating hormone (TSH) level, a low thyroxine (T4) level, and a positive anti-microsomal antibody screen. The patient also tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. Ultrasound of the patient's neck showed an enlarged heterogeneous thyroid gland. Thyroid replacement therapy with intravenous levothyroxine was started with the subsequent oral transition. Concurrently, she received antibiotics, steroids, and low-molecular-weight heparin for COVID-19. The patient exhibited significant improvement in her mental status, with an eventual return to baseline. The results of the thyroid panel obtained at the outpatient follow-up were normal. Although there is a paucity of data to show COVID-19 as a cause of this painless thyroiditis, this case demonstrates such causality between these two.

Comparison of Percutaneous Coronary Intervention Outcomes Among Patients With Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease Overlap, and Pickwickian Syndrome (Obesity Hypoventilation Syndrome).

Background Obstructive sleep apnea (OSA) is often present in coronary artery disease patients and confers a high risk of complications following percutaneous coronary interventions (PCI). The impact of two commonly associated comorbid conditions, chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS, Pickwickian syndrome) in OSA patients undergoing PCI has never been studied. Methods The National Inpatient Sample (NIS; 2007-2014) was queried using the International Classification of Diseases, Clinical Modification 9 (ICD-9-CM) codes to compare baseline characteristics, comorbidities, and outcomes in adults undergoing PCI with OSA, COPD-overlap syndrome, and OSA+OHS. Results Of a total of 4,792,177 PCI-related inpatient encounters, OSA, OSA-COPD overlap syndrome, and OSA+OHS were found to be present in 153,706 (median age 62 years, 79.4% male), 65135 (median age 65 years, 66.0% male), and 2291 (median age 63 years, 58.2% males) patients, respectively. The OHS+OSA cohort, when compared to the COPD-OSA and OSA cohorts, was found to have the worst outcomes in terms of all-cause mortality (2.8% vs. 1.5% vs. 1.1%), hospital stay (median 6 vs. 3 vs. 2 days), hospital charges ($147, 209 vs. $101,416 vs. $87,983). Complications, including cardiogenic shock (7.3% vs. 3.4% vs. 2.6%), post-procedural myocardial infarction (11.2% vs. 7.1% vs. 6.0%), iatrogenic cardiac complications (6.1% vs. 3.5% vs. 3.7%), respiratory failure, acute kidney injury, infections, and pulmonary embolism, were also significantly higher in patients with OHS+OSA. Adjusted multivariable analysis revealed equivalent results with OHS+OSA having worse outcomes than OSA-COPD and OSA. Conclusion Concomitant OHS and COPD were linked to worse clinical outcomes in patients with OSA undergoing PCI. Future prospective studies are warranted to fully understand related pathophysiology, evaluate and validate long-term outcomes, and formulate effective preventive and management strategies.

Aortic valve myxoma-A systematic review of published cases.

BACKGROUND: Aortic valve myxoma is the rarest location of the most common primary tumour of cardiac origin. Because of the paucity of data, there is little known about their clinical presentation, diagnosis and complications. METHODS: PUBMED, EMBASE, SCOPUS and WEB OF SCIENCE were systematically searched to identify all published cases of aortic valve myxoma through October 2020. Descriptive statistics were used to report the data. RESULTS: Aortic valve myxomas were more prevalent in young (mean age 41 years) male (75%) patients. It most commonly involved the right coronary cusp (50%). Cerebrovascular events (25%), dyspnoea (18.8%), and distal embolisation (18.8%) were found to be the most frequent complications. Echocardiography remains the diagnostic modality of choice in all cases, histopathology is used for confirmation. Most cases were treated with surgical excision (94%); concomitant aortic valve repair and mechanical aortic valve replacement were performed in 25% and 37.5% cases respectively. Sudden cardiac death was noted in one patient. CONCLUSION: Aortic valve myxomas are more often than not discovered in the context of embolic phenomenon or dyspnoea. The most feared complication is stroke, although mortality remains low in surgically managed cases.

Impact of alcohol use disorder on stroke risk in geriatric patients with prediabetes: A nationwide analysis.

BACKGROUND: With rising trends of prediabetes in the geriatric population, we aim to assess the impact of alcohol use disorder (AUD) on the outcomes of patients with prediabetes. METHODS: Hospitalisations amongst the patients (≥65 years) with prediabetes were identified with a diagnosis of AUD and in-hospital stroke using the National Inpatient Sample database (2007-2014). We compared demographics, comorbidities, all-cause mortality, stroke rate and resource utilisation in the elderly prediabetes patients with vs without AUD. Primary outcomes of interest were all-cause mortality and stroke rate, whereas secondary outcomes were the length of stay (days), disposition and resource utilisation in the AUD cohort as compared to the non-AUD cohort. RESULTS: We had a total of 1.7 million hospitalisations amongst elderly patients with prediabetes, 2.8% (n = 47 962) had AUD. The AUD cohort was more often younger (71 vs 77 years), male (74.1% vs 43.5%) and nonelectively (84.5% vs 78.3%) admitted than non-AUD cohort. The AUD cohort more often consisted of African Americans (9.0% vs 6.6%) and Hispanics (5.3% vs 5.1%) than non-AUD cohort. The AUD cohort showed higher rates of smoking, drug abuse, chronic obstructive pulmonary disease, coagulopathy, peripheral vascular disease and fluid-electrolyte disorders whereas a lower rate of cardiovascular risk factors than non-AUD cohort. All-cause mortality (4.4% vs 3.9%) and stroke (5.5% vs 4.8%, aOR 1.33, 95% CI 1.28-1.39) were significantly higher in the AUD cohort with prolonged stay, higher charges and frequent transfers than non-AUD cohort. CONCLUSION: AUD in the elderly prediabetes patients increases the stroke risk by up to 33% which can adversely influence the survival rate and healthcare infrastructure.

Alarmingly Increased Public Interest in "Chest Pain" During the COVID-19 Pandemic: Insights From Google Trends Analysis.

Background The coronavirus disease 2019 (COVID-19) pandemic has been linked to a myriad of cardiac symptoms and disorders. Reports also suggest decreased hospital visits by patients with known cardiovascular disorders. Methodology To better elucidate the public interest in the information regarding "chest pain" during the COVID-19 pandemic, we conducted a Google Trends analysis from March 2019 to March 2021 to compare the internet searches between pre-COVID era and during the pandemic with country-wise [the United States (US) versus the United Kingdom (UK) versus India] variation. Results We observed a significantly rising public interest in "chest pain" internet searches during the peak COVID-19 pandemic. Rising trends were most prominent in the UK, followed by USA and India. Our analysis noted a spike in the trend of "chest pain" search in early March in the UK and USA, whereas in March and June 2020 for India. This shows an important temporal association between the surge of COVID-19 cases and the search for "chest pain" online. Conclusion Google Trends analyses indicate rising public interest in chest pain during the pandemic months and the possible association between COVID-19 and chest pain. These findings warrant further research, especially with increasing reports suggesting contradictory reports of decreased hospital visits by patients with known cardiovascular diseases.

Portal Cholangiopathy: An Uncommon Cause of Right Upper Quadrant Pain.

Portal cholangiopathy is one of the complications of the chronic portal vein thrombosis (PVT). Chronic PVT can occur in a patient with acute PVT that usually does not resolve regardless of the treatment. There is a development of collateral blood vessels that bring blood from the portal system towards the liver around the obstruction area, known as the cavernous transformation of the portal vein or portal cavernoma, in a patient with chronic PVT. The appearance and location of collateral channels depends on the extent and location of thrombus in the portomesenteric venous system. If the portomesenteric venous system is occluded near the formation of the portal vein, blood tends to flow through collateral channels that form varices in and around the common bile duct. Portal cholangiopathy (also referred to as portal biliopathy) is common in patients with long-standing chronic PVT. It is due to compression of the large bile ducts by the venous collaterals that form in patients with chronic PVT. Most of the patients with long-standing PVT have portal cholangiopathy. Typically, symptoms of portal cholangiopathy include jaundice, biliary colic, and pruritus. Portal cholangiopathy is a rare complication of chronic portal hypertension, and it is an important differential diagnosis of biliary colic secondary to cholelithiasis. The patient can also present with the sharp right upper quadrant pain, which is atypical by nature for biliary colic.

Rising Trends in Medication Non-compliance and Associated Worsening Cardiovascular and Cerebrovascular Outcomes Among Hospitalized Adults Across the United States.

Introduction Small-scale studies have described concerning rates of non-compliance/nonadherence towards groups of medications for primary and secondary prevention. Trends in cardiovascular and cerebrovascular events (CCE) among hospitalized patients with a non-compliant behavior towards medication, on the whole, remains unexplored on a large scale. Methods Using the National Inpatient Sample databases (2007-2014), we sought to assess the prevalence and trends in all-cause mortality and CCE in adult patients hospitalized with medication non-compliance. We compared baseline characteristics and comorbidities in the non-compliant patients with and without concomitant in-hospital CCE. Results We identified 7,453,831 adult hospitalizations with medication non-compliance from 2007 to 2014, of which 867,997 (11.6%) patients demonstrated in-hospital CCE. Non-compliant patients with CCE consisted of a higher number of older, white, male patients having greater comorbid risk factors. Non-compliant patients with CCE had higher all-cause in-hospital mortality (3% vs. 0.7%), frequent transfers [4.4% vs. 1.8% transfers to short-term hospitals, and 17.6% vs. 11.6% other transfers (skilled nursing or intermediate care facilities)], lower routine discharges (59.4% vs. 71.1%), and higher mean hospital charges ($52,740 vs. $30,748) compared to non-compliant patients without CCE. Remarkably, this study demonstrates the rising trend in medication non-compliance across all age, sex, and race groups, and related in-hospital mortality, CCE, transfers to other facilities, and the health care cost from 2007 to 2014. Conclusions We observed rising trends in the prevalence of medication non-compliance and subsequent in-hospital mortality in hospitalizations among adults from 2007 to 2014. Non-compliant patients with inpatient CCE demonstrated rising trends in all-cause mortality, complications, health care utilization, and cost from 2007 to 2014.